POPULATION HEALTH CREATING A CULTURE OF WELLNESS. Dean. Jefferson School of Population Health Thomas Jefferson University

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1 & POPULATION HEALTH CREATING A CULTURE OF WELLNESS David B. Nash, NOT FOR MD, MBA Dean Jefferson School of Population Health Thomas Jefferson University NOT FOR SALE JoAnne OR Reifsnyder, DISTRIBUTION PhD, ACHPN Senior Vice President Care Transitions CareKinesis, Inc. Raymond J. Fabius, MD Chief Medical Officer Thomson Reuters, Healthcare and Science Valerie P. Pracilio, MPH Project Manager for Quality Improvement Jefferson School of Population Health Thomas Jefferson University..

2 & World Headquarters & Learning 40 Tall Pine Drive Sudbury, MA & Learning Canada 6339 Ormindale Way Mississauga, Ontario L5V 1J2 Canada & Learning International Barb House, Barb Mews London W6 7PA United Kingdom & Learning books and products are available through most bookstores and online booksellers. To contact & Learning directly, call , fax , or visit our website, Substantial discounts on bulk quantities of & Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at & Learning via the above contact information or send an to Copyright 2011 by & All rights reserved. No part of the material protected NOT by this FOR copyright SALE may be OR reproduced DISTRIBUTION or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. & If legal advice or other expert assistance is required, the service of a competent professional person should be sought. Production Credits Publisher: Michael Brown Associate Editor: Catie Heverling Editorial Assistant: Teresa Reilly Associate & Production Editor: Tiffany Sliter NOT FOR Senior SALE Marketing OR Manager: DISTRIBUTION Sophie Fleck Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: Glyph International Cover Design: Scott Moden Cover Image: Vladislav Gajic/ShutterStock, Inc. Printing and Binding: Malloy, Inc. Cover Printing: Malloy, Inc. Library of Congress Cataloging-in-Publication Data Population health: creating a culture of wellness / David B. Nash... [et. al.]. p. ; cm. Includes bibliographical references and index ISBN-13: (pbk.) ISBN-10: X (pbk.) 1. Medical care United States. 2. Health promotion United States. 3. Health education United States. I. Nash, David B. [DNLM: 1. Delivery of Health Care organization & administration United States. 2. Delivery of Health Care economics United States 3. Disease Management United States. 4. Health NOT Care FOR Reform United SALE OR States. DISTRIBUTION 5 Health Promotion United States. W 84 AA1 P ] RA395.A3P dc Printed in the United States of America

3 & Dedication To Es, Leah, Rachel, and Jake, we remember AJN with love. DBN & To Rachel, my inspiration. JR To my mentors, my friends, and my family, especially my Sara, Mike, and Dan. RJF To my family, friends, and mentors (DS and CB) who have supported me in my endeavors. & VPP and To our current and future students who challenge us with their complex questions and whose quest for solutions will bring about much needed improvements in population health...

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5 & CONTENTS About the Authors xvii NOT FOR Foreword SALE. OR.... DISTRIBUTION NOT..... FOR.. xxiii SALE OR DI Preface xxvii Contributors xxxi The & Population Health Mandate & xxxv Valerie P. Pracilio, MPH, JoAnne Reifsnyder, NOT PhD, FOR ACHPN, David B. Nash, MD, MBA, and Raymond J. Fabius, MD Section i. providing population Health Chapter 1 The Spectrum of Care Jaan Sidorov, MD, MHSA, and Martha Romney, MS, JD, MPH Introduction What Is Population Health and Why Is This Approach Necessary? & Attributes of the Population Health Paradigm & 6 Lea NOT FOR Components of the Population Health Paradigm.... NOT..... FOR.... 7SALE OR D Health Promotion Prevention Screening & Behavior Change (Health Management) & Patient Self-Care v..

6 & vi Contents & Patient-Centered Medical Home & 10 Lea NOT FOR Chronic SALE OR Care DISTRIBUTION Management and Disease Management. NOT..... FOR SALE OR DI Eliminating Health Disparities Cultural Competency National Initiatives Addressing Population Health Needs The National Priorities Partnership & Healthy People Initiatives & State-Based Initiatives NOT FOR..... SALE OR.... DISTRIBUTION. 15 Challenges in Implementing a Population Health Approach Clinical Policy Business & Conclusions NOT..... FOR SALE OR.... DISTRIBUTION Study and Discussion Questions Suggested Readings and Web Sites Readings Web Sites References. & & 19 Lea Chapter 2 Behavior Change James O. Prochaska, PhD, and Janice M. Prochaska, PhD Introduction & The Transtheoretical Model of Behavior Change.. & Core Constructs NOT..... FOR SALE OR.... DISTRIBUTION. 25 Stages of Change Processes of Change Decisional Balance Self-Efficacy Temptation & Critical Assumptions NOT..... FOR SALE OR.... DISTRIBUTION Empirical Support and Challenges Stage Distribution Pros and Cons Structure Across 12 Behaviors & Integration of Pros and Cons and Stages of Change Across 12 Health Behaviors Strong and Weak Principles of Progress Processes of Change Across Behaviors Relationship Between Stages and Processes of Change Applied Studies & Multiple Behavior Change Programs: Increasing Impact & Future Research NOT..... FOR..... SALE OR.... DISTRIBUTION. 36..

7 & Contents vii Future & Practice & 37 Lea NOT FOR Conclusions SALE OR... DISTRIBUTION NOT FOR SALE OR DI Study and Discussion Questions Suggested Readings and Web Sites Readings Web Sites & References & Chapter 3 health System Navigation: The Role of Health Advocacy and Assistance Programs Abbie Leibowitz, MD, FAAP Introduction & The Emergence of Health NOT Advocacy FOR SALE and Assistance OR DISTRIBUTION Programs Goals of Advocacy and Assistance Programs The Constituents The Employers Perspective The Consumer s Perspective Consumer-Driven Health Care.. 50 & The Physician s Perspective & 51 Lea NOT FOR The SALE Perspective OR DISTRIBUTION of Health Plans and Administrators. NOT FOR SALE OR DI Health Advocacy as an Independent Service A Matter of Trust What Help Do Consumers Need? & Access to Care & Making Connections Across the Spectrum NOT of Care FOR.. SALE OR.... DISTRIBUTION. 57 Coordinating Care Across Benefits Programs Changing Consumer Behavior Conclusions Study and Discussion Questions Suggested Readings and Web Sites & Readings NOT..... FOR SALE OR.... DISTRIBUTION Web Sites References Chapter 4 Continuity & of Care & 63 Lea JoAnne Reifsnyder, PhD, ACHPN, and Theresa P. Yeo, PhD, MPH, MSN, CRNP Introduction Risk Factors for Chronic Disease Overview of Chronic Conditions & Diabetes & Cancer NOT..... FOR..... SALE OR.... DISTRIBUTION. 67..

8 & viii Contents & Cardiovascular Disease & 69 Lea NOT FOR Asthma. SALE OR.... DISTRIBUTION NOT FOR SALE OR DI Mental Health Disorders Impact of Chronic Conditions Care Delivery Variation Chronic Care Management & Self-Management of Chronic Conditions..... & Chronic Disease Self-Management Program NOT FOR..... SALE OR.... DISTRIBUTION. 73 The Wagner Chronic Care Model Publicly Funded Home- and Community-Based Services State Home- and Community-Based Models Program of All-Inclusive Care for & the Elderly Physician Practice-Centered NOT Models. FOR SALE OR.... DISTRIBUTION Patient-Centered Medical Home Guided Care Community-Based, Fee-for-Service Model: Geriatric Care Management Palliative & and End-of-Life Care & 80 Lea NOT FOR Workforce SALE OR Needs DISTRIBUTION for an Aging Society with Increasing Chronic Illness Conclusions Study and Discussion Questions & Suggested Readings and Web Sites & Readings NOT..... FOR SALE OR.... DISTRIBUTION. 84 Web Sites References Chapter 5 Population Health Quality and Safety Susan DesHarnais, PhD, MPH, and & Valerie P. Pracilio, MPH Introduction NOT..... FOR SALE OR.... DISTRIBUTION Advances in Quality and Safety What Has Worked Reducing Fragmentation A & Framework for Achieving Health and Wellness & 94 Lea Quality and Safety Measurement: The Consumer s Perspective A Consumer s View of Quality and Safety An Institution s View of Quality and Safety Creating an Epidemic of Health and Wellness Epidemiological Factors & Achieving Health and Wellness &

9 & Contents ix Conclusions & & Lea NOT FOR Study SALE and Discussion OR DISTRIBUTION Questions NOT FOR SALE OR DI Suggested Readings and Web Sites Readings Web Sites References NOT FOR Chapter SALE OR 6 DISTRIBUTION risk Management and Law NOT..... FOR..... SALE OR... DISTRIBUTION 105 Henry C. Fader, Esq. Introduction The Role of Law Patient Advocacy & Provider Advocacy. NOT..... FOR SALE OR.... DISTRIBUTION Advocating for Population Health and Wellness Tax Status Employer-Based Health Insurance Conclusions Study & and Discussion Questions & Lea NOT FOR Suggested SALE Readings OR DISTRIBUTION and Web Sites NOT FOR SALE OR DI Readings Web Sites References NOT FOR Section SALE OR ii. The DISTRIBUTION Business of health Chapter 7 Making the Case for Population Health Management: The Business Value of Better Health Ronald R. Loeppke, MD, MPH, FACOEM, FACPM Introduction & The Business Case for Good NOT Health FOR SALE OR.... DISTRIBUTION Relationship Between Health and Productivity Impact of Productivity on Business Workforce Issues Access & to Care and Disparities & Lea Key Players in Population Health Management The Purchaser s Role The Health Plan s Role The Healthcare Consultant s Role The Specialty Vendor s Role & The Value of Population Health Management Strategies & Making the Business Case NOT..... FOR..... SALE OR.... DISTRIBUTION 132..

10 & x Contents Conclusions & & Lea NOT FOR Study SALE and Discussion OR DISTRIBUTION Questions NOT FOR SALE OR DI Suggested Readings and Web Sites Readings Web Sites References NOT FOR Chapter SALE OR 8 DISTRIBUTION The Business Case for Cultural Change: From Individuals to Communities Mario Moussa, PhD, MBA, and Jennifer Tomasik, MS Introduction What Is the Cost? & Populations vs. Patients NOT.... FOR SALE OR.... DISTRIBUTION Preventive vs. Reactive Chronic Conditions vs. Acute Conditions Integrated Healthcare Teams vs. Physicians Communities vs. Individuals Conclusions & & Lea NOT FOR Study SALE and Discussion OR DISTRIBUTION Questions NOT FOR SALE OR DI Suggested Readings and Web Sites Readings Web Sites & References & Chapter 9 Information Technology John K. Cuddeback, MD, PhD, and Donald W. Fisher, PhD Introduction From Paper Medical Records to the EHR Inferential Gap & Structured Data... NOT..... FOR SALE OR.... DISTRIBUTION Patient- and Population-Level Clinical Decision Support Systems and Data Sources Other than the EHR Administrative Systems & System Architecture & Lea Claims Data Three Major Categories of Systems Transaction Systems Data Warehouses Disease Registries

11 & Contents xi Creating & Data Warehouses & Lea NOT FOR Mapping SALE OR to Common DISTRIBUTION Terminology NOT FOR SALE OR DI Challenges in Creating Data Warehouses Public Health Informatics Practical Issues of EHR Implementation and Adoption Importance of Process Redesign and Cognitive Support & Impact of Organizational Culture & Incentives for E-Prescribing and Meaningful NOT FOR Use SALE of EHRs OR.. DISTRIBUTION 174 Interoperability Privacy and Security Unintended Consequences Conclusions & Study and Discussion Questions NOT FOR... SALE OR.... DISTRIBUTION Suggested Readings and Web Sites Readings Web Sites References Chapter NOT 10 FOR Decision SALE Support OR DISTRIBUTION NOT..... FOR SALE OR DI Matthew C. Stiefel, MPA Introduction Three Main Purposes for Measurement in Population Health & Measurement for Improvement & The Model for Improvement NOT..... FOR SALE OR.... DISTRIBUTION 182 Predictive Modeling Measurement for Accountability Measuring the Triple Aim Measuring Value and Efficiency Measurement for Research & Conclusions NOT..... FOR SALE OR.... DISTRIBUTION Study and Discussion Questions Suggested Readings and Web Sites Readings & Web Sites & Lea References Chapter 11 Marketing and Communication: Methods for Reaching Populations William Haggett, EdD & Introduction & Engaging the Consumer NOT..... FOR..... SALE OR.... DISTRIBUTION 200..

12 & xii Contents Communication & Strategies from Other Industries & Lea NOT FOR Why SALE Communicate? OR DISTRIBUTION What Is the Communication Objective?. NOT. FOR SALE OR DI Who Is the Audience? What Is the Message? How Should You Communicate? What Works? & Conclusions & Study and Discussion Questions..... NOT FOR..... SALE OR.... DISTRIBUTION 210 Suggested Readings and Web Sites Readings Web Sites References & Section iii. making policy to advance population health Chapter 12 Policy Implications for Population Health: Health Promotion and Wellness Tracey & Moorhead, Jeanette C. May, PhD, MPH, and Kip MacArthur NOT FOR Introduction SALE OR... DISTRIBUTION NOT FOR SALE OR DI Key Players in Federal Policy Making Overview of Historical Demonstrations and Pilots State Case Studies in Disease Management & Key Considerations in Policy Development & Conclusions NOT..... FOR SALE OR.... DISTRIBUTION 224 Study and Discussion Questions Suggested Readings and Web Sites Readings Web Sites References & Chapter 13 Ethical Dimensions of Population Health Francis Barchi, MS, MBE Introduction The & Role of Ethics Population Health & Lea Distinction between Ethics in Population Health and Medical Ethics Moral Traditions and Theories Ethics in Population Health Practice Ethics in Population Health Research & Allocation of Resources and Access & Ethical Reflection and Decision Making NOT in Population FOR SALE Health OR... DISTRIBUTION 236..

13 & Contents xiii Conclusions & & Lea NOT FOR Study SALE and Discussion OR DISTRIBUTION Questions NOT FOR SALE OR DI Suggested Readings and Web Sites Readings Web Sites References NOT FOR Chapter SALE OR 14 DISTRIBUTION Population Health in Action: Successful NOT Models FOR.. SALE OR... DISTRIBUTION 241 Paul Wallace, MD Introduction Why Focus on Chronic Medical Conditions? Care as Usual & Disease Management NOT and Practice FOR SALE Redesign OR.. DISTRIBUTION Gauging Success Assessment Framework Disease Management: A Model for Population Care Access and Spread Disease Management and Medicare & Disease Management and Medicaid & Lea NOT FOR An SALE Alternative OR Model: DISTRIBUTION Clinical Practice Redesign..... NOT FOR SALE OR DI The Chronic Care Model Practice Redesign and Integrated Delivery Systems PR in the Safety Net and Medicaid & Conclusions & Study and Discussion Questions..... NOT..... FOR SALE OR.... DISTRIBUTION 253 Suggested Readings and Web Sites Readings Web Sites References Chapter 15 Research and Development NOT in FOR Population SALE OR Health DISTRIBUTION R. Dixon Thayer, Raymond J. Fabius, MD, and Sharon Frazee, PhD Introduction Effective Population Health Research State & of the Art of Population Health Measurement & Lea The View from the Five Constituencies of Health Care Classes of Measures Techniques of Measurement Challenges to Successful Research Establishing Goals & The Five Segments of Population Health Status...& Conclusions NOT..... FOR..... SALE OR.... DISTRIBUTION 267..

14 & xiv Contents Study & and Discussion Questions & Lea NOT FOR Suggested SALE Readings OR DISTRIBUTION and Web Sites NOT FOR SALE OR DI Readings Web Sites References Chapter & 16 Population Health Education & Brooke Salzman, MD, James D. Plumb, MD, NOT MPH, FOR and Richard Wender, MD Introduction The Need for Health Professional Education Reform The Need for a Population Health & Approach to Health Professions NOT Education FOR. SALE OR.... DISTRIBUTION Establishing a Framework in Population Health Education Examples of Developed Frameworks in Population Health and Strategies for Implementation Challenges and Barriers to Health Professions Education & Reform and Implementing Curricula in Population Health & Lea NOT FOR Composition of the Population of Learners NOT FOR SALE OR DI Characteristics of the Learning Environment Organization Structures and Sources of Support Recommendations & Conclusions & Study and Discussion Questions..... NOT..... FOR SALE OR.... DISTRIBUTION 289 Suggested Readings and Web Sites Readings Web Sites References Chapter 17 The Political Landscape NOT in Relation FOR SALE to OR DISTRIBUTION the Health and Wealth of Nations Alan Lyles, ScD, MPH, RPh Introduction Measuring & and Comparing Population Health and Wealth & Lea Health Wealth Health and Disparities Federalism, Politics, and Population Health Interest Groups: The First Amendment, Pluralism, & and Political Campaign Financing & Public Private Sector Arrangements in NOT Health FOR Care SALE..... OR.... DISTRIBUTION 307 Conclusions

15 & Contents xv Study & and Discussion Questions & Lea NOT FOR Suggested SALE Readings OR DISTRIBUTION and Web Sites NOT FOR SALE OR DI Readings Web Sites References The & Future of PopuLATion HeALTh: Moving Upstream. & Dee W. Edington, PhD, and Alyssa B. Schultz, NOT PhD FOR Introduction A Brief History of Population Health The Past: Prior to The Past: Status of Population Health: & The Past: Emergence NOT of Population FOR SALE Health: OR DISTRIBUTION Future Trends in Population Health Management The Future: Near- to Mid-Term: Natural Flow of a Population among Health Risk Categories Natural Distribution of Healthcare Costs & Information Technology & Lea NOT FOR Culture SALE OR of Health. DISTRIBUTION NOT FOR SALE OR DI The Future: Longer Term, 2015 and Beyond Precursors to Beyond Wellness (Totally Upstream) Conclusions & Study and Discussion Questions & Suggested Readings and Web Sites.... NOT..... FOR SALE OR.... DISTRIBUTION 325 Readings Web Sites References Appendix Case Studies & Section I: Providing Population NOT FOR Health SALE.... OR.... DISTRIBUTION Behavior Change Risk Management and Law Section II: The Business of Health & Employee Health & Lea Decision Support Section III: Making Policy to Advance Population Health Ethics and Population Health References & Glossary & Index

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17 & About the Authors David B. Nash, MD, MBA Dr. Nash, a board-certified & internist, founded the original Office of Health Policy in & Lea Thirteen NOT years FOR later, SALE the Office OR evolved DISTRIBUTION into one of the first Departments NOT of Health FOR Policy SALE OR DI in an American medical college. In 2008, the Board of Thomas Jefferson University approved the creation of the new school. The Jefferson School of Population Health represents the first time a health-sciences university has placed four Masters Programs under one roof, namely a Masters in Public Health, Health Policy, Healthcare Quality, & and Safety and Chronic Care Management. The goal of this innovative & school is to NOT FOR produce SALE a OR new DISTRIBUTION type of healthcare leader for the future. Dr. Nash is internationally recognized for his work in outcomes management, medical staff development, and quality-of-care improvement; his publications have appeared in more than 100 articles in major journals. He has edited nineteen books, including A Systems Approach to Disease Management published by Jossey-Bass, & Connecting with the New Healthcare Consumer published by Aspen, The Quality Solution published by & Practicing Medicine in the 21st Century published by the American College of Physician Executives (ACPE), and most recently, Governance for Healthcare Providers published by Productivity Press. In 1995, he was awarded the Latiolais ( Lay-shee-o-lay ) Prize by the Academy of Managed Care Pharmacy for his leadership in disease management and pharmacoeconomics. & He also received the Philadelphia Business Journal Healthcare & Lea Heroes NOT Award FOR in October SALE 1997 OR DISTRIBUTION and was named an honorary distinguished NOT fellow FOR of the SALE OR D American College of Physician Executives in In 2006, he received the Elliot M. Stone Award for leadership in public accountability for health data from NAHDO. Dr. Nash received the Wharton Healthcare Alumni Achievement Award in & Repeatedly named by Modern Healthcare as one of the top 100 most & powerful persons in healthcare, his national activities include membership on the board of directors of DMAA: xvii..

18 & xviii About The Authors The Care Continuum & Alliance, Chair of an NQF Technical Advisory Panel, membership & Lea in the NOT American FOR College SALE of OR Surgeons DISTRIBUTION Health Policy Research Institute, three NOT key FOR national SALE OR DI groups focusing on quality measurement and improvement. He continues as one of the principal faculty members for quality of care issues of the ACPE in Tampa, Florida, and is the developer of the ACPE Capstone Course on Quality. For the last decade, he was a member of the board of trustees of Catholic Healthcare Partners in Cincinnati, Ohio one & of the nation s largest integrated delivery systems and he chaired the & Board Committee on NOT FOR Quality SALE and OR Safety. DISTRIBUTION He was recently appointed to the board NOT of FOR Main Line SALE Health a OR DISTRIBUTION four hospital system in suburban Philadelphia, Pennsylvania. He also serves on the board of directors of Humana, a Fortune 200 company headquartered in Louisville, Kentucky. Dr. Nash is a consultant to organizations in both the public and private sectors includ- the Technical Advisory Group of the Pennsylvania & Health Care Cost Containment Council (a group he has chaired for the NOT last decade), FOR SALE and numerous OR DISTRIBUTION corporations within the pharmaceutical industry. From 1984 to 1989, he was deputy editor of Annals of Internal Medicine at the American College of Physicians. Currently, he is editor-in-chief of four major national journals including P&T, Population Health Management, Biotechnology Healthcare, and the American Journal of Medical Quality. Through his writings, public appearances, and & his digital presence, his message reaches more than 100,000 persons & Lea every NOT month. FOR Dr. Nash received his BA in economics (Phi Beta Kappa) from Vassar College, Poughkeepsie, New York; his MD from the University of Rochester School of Medicine and Dentistry, where he was recently named to the Alumni Council, and his MBA in Health & Administration (with honors) from the Wharton School at the University & of Pennsylvania. NOT FOR While SALE at OR the University DISTRIBUTION of Pennsylvania, he was a Robert NOT Wood FOR Johnson SALE Foundation OR DISTRIBUTION Clinical Scholar and Medical Director of a nine-physician faculty group practice in general internal medicine. Dr. Nash lives in Lafayette Hill, Pennsylvania, with his wife, Esther J. Nash, MD, fraternal twin twenty-three-year-old daughters, and nineteen-year-old son. He is an avid tennis player. Please visit: & and his new blog at: NOT Dr. FOR Nash SALE can be OR contacted DISTRIBUTION at david.nash@ jefferson.edu. JoAnne Reifsnyder, PhD, ACHPN JoAnne Reifsnyder is an advanced practice nurse in palliative care with more than 25 years of experience in palliative and end-of-life care clinical practice, administration, consulting, education, and research. She completed a two-year postdoctoral fellowship in psychosocial oncology at University of Pennsylvania and holds a PhD in nursing from the University of Maryland, a Master s Degree in nursing from Thomas Jefferson University, and a BSN from Holy Family College. She led the development & of the first Masters & NOT FOR program SALE in OR Chronic DISTRIBUTION Care Management at Jefferson School NOT of Population FOR SALE Health OR (JSPH), DISTRIBUTION..

19 & About The Authors xix Thomas Jefferson & University in Philadelphia, Pennsylvania, and formerly served as Program & Lea Director. NOT She FOR also SALE served as OR chief DISTRIBUTION quality outcomes officer for excellerx, NOT Inc., the FOR parent SALE OR DI company of Hospice Pharmacia, where she led a group of researchers and clinicians in an agenda that included health services research, development of clinical decision support and QAPI tools, and dissemination of findings through publication and presentation. Dr. Reifsnyder was co-founder and partner in Ethos Consulting Group,, a company & focused on program development, education/training, and research/evaluation & to advance NOT FOR end-of-life SALE OR care. DISTRIBUTION She has been the director of the hospice NOT program FOR for SALE the Visiting OR DISTRIBUTION Nurse Association of Greater Philadelphia and was director of Patient Services for Samaritan Hospice, located in Marlton, New Jersey. Reifsnyder codeveloped and is the coordina tor of a palliative care minor at the University of Pennsylvania School of Nursing, and taught both core courses in palliative care to nursing, & social work, and medical students. Dr. Reifsnyder is the President of the NOT Board FOR of Directors SALE OR for DISTRIBUTION Pennsylvania Hospice Network, and a Board Member for both the Hospice Foundation of America and the Hospice and Palliative Nurses Association. She speaks frequently on topics related to palliative care program development, policy and regulatory issues, and ethics. Dr. Reifsnyder can be contacted at joanne.reifsnyder@yahoo.com. Raymond J. Fabius, MD Dr. Fabius currently serves as Chief Medical Officer of Thomson Reuters Healthcare and Science the world s leading source of intelligent information for businesses and professionals. & Thomson Reuters combines industry expertise with innovative technology & to deliver critical NOT FOR information SALE OR to DISTRIBUTION leading decision makers in the financial, legal, NOT tax FOR and accounting, SALE OR healthcare DISTRIBUTION and science, and media markets, powered by the world s most trusted news organization. As CMO, Dr. Fabius spearheads thought leadership efforts, develops and deepens relationships with customers, advises on product development, and provides counsel to Thomson Reuters on medical issues. Previously Dr. Fabius served as strategic advisor to & the president of Walgreens Health and Wellness division. In this role, he provided NOT guidance FOR to SALE integrate OR an array DISTRIBUTION of services through their extensive national network of pharmacies, many with retail clinics, workplace health and fitness centers, and infusion therapy sites, into a seamless population health network. Dr. Fabius is the principal of Ab3Health,, and a founder of HealthNEXT, two organizations focused & on population health, health and productivity, and building organizational cultures of health. To accomplish this, both entities utilize the five-stage & Lea road-map advocated by the American College of Occupational and Environmental Medicine as well as Six Sigma methodology. During the assessment process, organizations are compared to benchmarks to determine gaps, which are then prioritized in an implementation plan to achieve best practice. & Dr. Fabius was I-trax (AMEX:DMX)/CHD Meridian s President & and Chief Medical NOT FOR Officer SALE for OR the DISTRIBUTION three years prior to its sale to Walgreens. NOT During FOR this tenure, SALE he OR served DISTRIBUTION on..

20 & xx About The Authors the board of directors & and was principally responsible for converting this financially struggling NOT organization FOR SALE into a workplace OR DISTRIBUTION health leader while quadrupling the NOT DMX FOR market SALE OR DI & Lea capitalization. CHD Meridian operated over 300 workplace health centers providing fitness centers, wellness programming, occupational health, acute episodic illness treatment, and comprehensive primary care and pharmacy services. Leveraging the trusted clinician at the workplace, I-trax integrated wellness, disease, and disability management & programs within the proven advantaged on-site model. In his role & Dr. Fabius provided NOT FOR visionary SALE guidance, OR DISTRIBUTION new product development, clinical NOT leadership, FOR as SALE well as OR setting DISTRIBUTION the research and development agenda. Dr. Fabius also served previously as global medical leader of General Electric, responsible for the health and safety of over 330, 000 employees worldwide. He spent his first decade medical management within the health plan & space, serving as a regional medical director and then corporate medical director NOT for FOR Cigna, SALE U.S. OR Healthcare, DISTRIBUTION and Aetna. This included leadership roles in utilization, disease and quality management, national accounts, e-health, and health informatics. Dr. Fabius is boarded in pediatrics and medical management and has written two other books. The most recent one, Total Care Management, was published by the American College of Physician & Executives and received the ACPE Robert A. Henry Literary Book & Lea Award NOT in FOR Dr. SALE Fabius OR can DISTRIBUTION be contacted at raymond.fabius@thomsonreuters.com. Valerie P. Pracilio, MPH & Valerie P. Pracilio is a Project Manager for quality improvement in & the Jefferson School NOT FOR of SALE Population OR Health DISTRIBUTION at Thomas Jefferson University, where NOT she FOR is responsible SALE for OR organizing efforts on various research projects that are primarily related to healthcare quality and DISTRIBUTION patient safety improvement. At Thomas Jefferson University, she is currently facilitating performance improvement initiatives in each of the Jefferson University Physician ambulatory practices and serves as a member of the Jefferson Clinical Care Subcommittee. & Ms. Pracilio is working to implement a smoking cessation initiative NOT across FOR all SALE Jefferson OR University DISTRIBUTION Physician (JUP) practices through funding from Pfizer Inc. and has been involved in evaluating provider participation in pay-for-performance programs. Ms. Pracilio is a graduate of the American Hospital Association (AHA) Patient Safety Leadership Fellowship. & Through this experience, she worked on an initiative for postdischarge medication reconciliation at Jefferson, with the goal of advancing patient safety & Lea and improving health outcomes. Ms. Pracilio currently serves as a medication safety expert on development of the Center for Medicare and Medicaid Services Physician Quality Reporting Initiative Measures. Ms. Pracilio s research interests include quality and patient safety, organizational & culture, teamwork and communication as well as oncology, and & public health. Her NOT FOR research SALE efforts OR DISTRIBUTION have included a project focused on the NOT capacity FOR for SALE colorectal OR DISTRIBUTION cancer..

21 & About The Authors xxi screening in Pennsylvania, & which was submitted to the Legislative Budget and Finance & Lea Committee, NOT FOR and an SALE initiative OR to DISTRIBUTION improve quality at two rural hospitals NOT in Pennsylvania FOR SALE OR DI through funding from State Representative Todd Eachus. Ms. Pracilio also served as managing editor and author of Governance for Health Care Providers: The Call to Leadership, which was published in 2008 by Productivity Press, New York, New York. & Ms. Pracilio has a bachelor s degree in Healthcare Administration & from the University NOT FOR of SALE Scranton OR and DISTRIBUTION a Masters of Public Health degree from NOT Thomas FOR Jefferson SALE OR University. DISTRIBUTION Ms. Pracilio can be contacted at valerie.pracilio@jefferson.edu...

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23 & Foreword In the past five years, I have had the opportunity to visit a number of medical practices and health plans transitioning from paper medical records to electronic health records. In one of my favorite & examples, Dr. Brent James of Intermountain Healthcare (IHC) & in Lea Utah NOT brought FOR me to SALE meet OR a late DISTRIBUTION adopter of the IHC electronic system. NOT This FOR physician SALE OR DI ruefully reported on his longstanding reluctance to convert to electronic records, and then delightedly showed me what the change had done for him. He pulled up charts and graphs for the patients in his panel to demonstrate the good results and continuous improvement & he had achieved for Hemoglobin A1C levels, an important indicator & of diabetes control. NOT FOR I SALE was watching OR DISTRIBUTION someone who had shifted his focus from NOT his FOR individual SALE patients OR DISTRIBUTION to the overall population he serves. With digitization of records and registries supported by good analytic tools, healthcare providers can move up from the assembly line to a more strategic view of their work. This is an example of the power of population health on the front lines at the provider level. The National Committee for Quality Assurance & (NCQA) has had an agenda rooted in population health since its inception. NOT As FOR we wrote SALE standards OR DISTRIBUTION for health plans and developed the Healthcare Effectiveness Data and Information Set (HEDIS), there were many heated arguments about the role of health maintenance organizations (HMOs) in holding the plan s entire population accountable, rather than limiting accountability to those who visited & their physicians. The beauty of the population view is that it offers & a Lea systematic approach to improving well-being and a framework for keeping track of our nation s health status, indicating where we are improving and where we need to adopt new strategies. Ten years ago, I had the opportunity to visit Bhutan, a country that is working on a project called the Gross National Happiness (GNH). Health status and healthcare were & considered foundational elements of the GNH, along with indicators & including average NOT FOR income, SALE educational OR DISTRIBUTION attainment, and forestation rate. The NOT work FOR being SALE done in OR Bhutan DISTRIBUTION is a xxiii..

24 & xxiv Foreword great example of population & health at the national level: the King and Parliament developed & Lea a set of NOT goals FOR and have SALE successfully OR DISTRIBUTION worked with their public health system NOT to achieve FOR them. SALE OR DI Accountability for population health is a more complex concept in the United States. The fragmented nature of healthcare and health insurance systems contributes to the complexity. In almost all the developed nations of the world, it is well understood that the health of the citizens is a national responsibility. This goes beyond the rhetorical & because the nation is either the insurer or the assembler of insurers in & a scheme that covers NOT FOR all SALE the citizens OR DISTRIBUTION and because it is usually (and more obviously) NOT FOR the SALE tax revenues OR DISTRIBUTION of the country that are paying for or arranging for services. In the United States, insurance may be obtained from the federal government, a state government, an employer, directly from an insurance company, or through some combination of these. Because we do not have a national consensus that health care is a good to & which all of our citizens are entitled, notions of accountability vary and often NOT citizens FOR are SALE grateful OR that DISTRIBUTION they have coverage and access to a source of care at all. Sorting out who is responsible for what is essential to achieving national goals. Another key issue is our emerging understanding of the important role of citizens or patients in their own health. We have come to understand, in a much more definitive way, that the healthcare & system has limits to what it can achieve and that the best health & care Lea can only NOT be FOR achieved SALE with the OR cooperation DISTRIBUTION and engagement of patients. Recent NOT reports FOR SALE on OR DI the social determinants of health also highlight the importance of this issue. We have begun to understand how to motivate patients and engagement strategies will remain an important part of the agenda for the next decade. The challenge is to help patients achieve & a level of understanding, motivate them to positively affect their own & health, and, ultimately, SALE to OR realize DISTRIBUTION or build their own self-efficacy. With new NOT technology, FOR SALE the patient OR DISTRIBUTION record NOT FOR can become a tool shared by patients and their providers. This has the potential to make the engagement of patients around their care a reality on a broad scale. Although there are important practical, ethical, and legal issues to be sorted out, much progress has been made by those who are already managing the health of populations. This book offers a primer on how the United States & can better manage population health, from wellness and health promotion to NOT chronic FOR disease SALE management, OR DISTRIBUTION to care of the frail elderly, and palliative care for those at the end of life. While the issues are different, the underlying techniques of population management are consistent: measuring the current state, determining what needs to be done, reaching out to those in need of intervention, and establishing & a new steady state. Although best individual results are achieved when & Lea each patient is supported according to his or her level of need, population health approaches address the broader landscape of healthcare consumers to preserve wellness and minimize the impact of illness. There are unparalleled opportunities today to move a vigorous population health agenda. Many health plans and systems have established a track record and expertise in & population health management, and they have good results to show & for it. A growing NOT FOR number SALE of OR medical DISTRIBUTION practices have embraced the medical NOT home FOR model, SALE which OR is based DISTRIBUTION on..

25 & Foreword xxv accountability for & a panel of patients and care coordination across settings. Larger entities, & Lea like medical NOT FOR groups, SALE hospitals, OR and DISTRIBUTION integrated delivery systems, seek to become NOT FOR accountable care organizations committed to maintaining the health status of a population. SALE OR DI These developments will be facilitated by another revolution: the widespread adoption of health information technology (HIT), thanks to the commitment of the federal government to reward adoption and meaningful use of HIT. HIT opens a number of & other new vistas: widespread implementation of decision support & systems, real-time NOT FOR research SALE using OR DISTRIBUTION the data made available by electronic health NOT records, FOR and SALE personal OR DISTRIBUTION health records that can make patient engagement much more real and meaningful. The road ahead, while exciting, is also fraught with challenges; however, the time to improve the health of Americans is now. Often, we are tempted to turn back or hunker down when the road ahead looks difficult. As with & most challenges, going back or staying put may sound like the easy or safe option, NOT but FOR that SALE is an illusion. OR DISTRIBUTION It is increasingly clear that both the health and the health care of Americans are on a worrisome downward trajectory. A population health strategy, enabled by the new tools offered by technology and coupled with learning collaboratives, offers our best hope for a healthy future for individual Americans and for the nation as a whole. Margaret O Kane President National Committee & for Quality Assurance..